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Community health worker knowledge and management of pre-eclampsia in southern Mozambique Boene, Helena; Vidler, Marianne; Augusto, Orvalho; Sidat, Mohsin; Macete, Eusébio; Menéndez, Clara; Sawchuck, Diane; Qureshi, Rahat; von Dadelszen, Peter; Munguambe, Khátia; Sevene, Esperança Sep 30, 2016

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RESEARCH Open AccessCommunity health worker knowledge andmanagement of pre-eclampsia in southernMozambiqueHelena Boene1, Marianne Vidler2, Orvalho Augusto1,3, Mohsin Sidat3, Eusébio Macete1,4, Clara Menéndez1,5,Diane Sawchuck6, Rahat Qureshi7, Peter von Dadelszen8, Khátia Munguambe1,3, Esperança Sevene1,3*and the CLIP Feasibility Working GroupAbstractBackground: Mozambique has drastically improved an array of health indicators in recent years, including maternalmortality rates which decreased 63 % from 1990–2013 but the rates still high. Pre-eclampsia and eclampsia constitute thethird major cause of maternal death in the country. Women in rural areas, with limited access to health facilities are atgreatest risk. This study aimed to assess the current state of knowledge and the regular practices regarding pre-eclampsiaand eclampsia by community health workers in southern Mozambique.Methods: This mixed methods study was conducted from 2013 to 2014, in Maputo and Gaza Provinces, southernMozambique. Self-administered questionnaires, in-depth interviews and focus group discussions were conducted withCHWs, district medical officers, community health workers’ supervisors, Gynaecologists-Obstetricians and matrons.Quantitative data were entered into a database written in REDCap and subsequently analyzed using Stata 13. Qualitativedata was imported into NVivo10 for thematic analysis.Results: Ninety-three percent of CHW had some awareness of pregnancy complications. Forty-one percent were able todescribe the signs and symptoms of hypertension. In cases of eclampsia, CHWs reported to immediately refer the women.The vast majority of the CHWs surveyed reported that they could neither measure blood pressure nor proteinuria (90 %).Fewer reported confidence in providing oral antihypertensives (14 %) or injections in pregnancy (5 %). The other communityhealth care providers are matrons. They do not formally offer health services, but assists pregnant women in case of anemergency. Regarding pre-eclampsia and eclampsia, matrons were unable to recognise these biomedical terms.Conclusions: Although CHWs are aware of pregnancy complications, they hold limited knowledge specific to pre-eclampsiaand eclampsia. There is a need to promote studies to evaluate the impact of enhancing their training to include additionalcontent related to the identification and management of pre-eclampsia and eclampsia.Keywords: Community health workers, Knowledge, Pre-eclampsia, Eclampsia management, MozambiqueAbbreviations: AMOG, Associação Moçambicana de Ginecologia; ANC, Antenatal care; AP, Administrative posts;APEs, Agentes Polivalentes Elementares; CHW, Community health worker; CISM, Manhiça health research center;CLIP, Community level interventions for pre-eclampsia; cRCT, Cluster randomized control trial; HDP, Hypertensive disorders ofpregnancy; LMIC, Low and middle-income countries; TBAs, Traditional birth attendants; UBC, University of British Columbia;WHO, World health organization* Correspondence: Esevene68@gmail.com1Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila daManhiça CP 1929, Moçambique3Universidade Eduardo Mondlane, Faculdade de Medicina, Av. SalvadorAllende, 702 R/C, Maputo, MoçambiqueFull list of author information is available at the end of the article© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.The Author(s) Reproductive Health 2016, 13(Suppl 2):105DOI 10.1186/s12978-016-0220-2Plain English summaryMaternal mortality is an important public health issue inMozambique despite the fact that some of these deathsare related to avoidable conditions. Women in ruralareas, with limited access to health facilities are the mostaffected. Hypertensive disorders of pregnancy (HDP) arethe third major cause of maternal death in the country.This study aimed to assess the current state of know-ledge and routine practices regarding HDP by commu-nity health workers (CHW). This mixed methods studywas conducted from 2013 to 2014, in southernMozambique involving CHWs, district medical officers,community health workers’ supervisors, Gynaecologists-Obstetricians and matrons. Ninety-three percent ofCHW had some awareness of pregnancy complicationsand forty-one percent were able to describe the signsand symptoms of hypertension. In case of severity,CHWs reported to immediately refer the women. Thevast majority of the CHWs surveyed reported that theycould neither measure blood pressure nor proteinuria(90 %). Fewer reported confidence in providing oral anti-hypertensives (14 %) or injections in pregnancy (5 %).Although CHWs are aware of pregnancy complications,they hold limited knowledge specific to HDP. There is aneed to promote studies to evaluate the impact of en-hancing their training to include additional content re-lated to the identification and management of HDP.BackgroundMozambique has progressively improved an array ofhealth indicators over the last two decades, including a63 % decrease in maternal mortality from 1,300 in 1990to 480 deaths per 100,000 live births in 2013 [1]. How-ever, women still have a 1 in 40 lifetime risk of maternaldeath [2] chiefly due to avoidable causes including post-partum hemorrhage, maternal sepsis and pre-eclampsiaand eclampsia that still need to be addressed [3, 4]. Thehypertensive disorders of pregnancy (HDP) contributesignificantly to high rates of maternal and perinataldeath. In Mozambique, eclampsia alone is the third mostcommon obstetric cause of maternal death [5]. Theshortage of health professionals capable of responding tothe need to reduce maternal mortality is also a concern.In 2011, the total number of medical doctors in the Na-tional Health System in Mozambique was 1,268 for apopulation of approximately 22.3 million people (5.6medical doctors per 100,000 inhabitants) [6], puttingMozambique in position of one of the worse countriesaccording to the World Health Organization (WHO)Work Force Observatory [7]. To overcome the shortageof medical doctors in the country, nurses and clinical of-ficers have been trained to take some of their duties [8].To best reach vulnerable population in light of the1978 Alma Ata Declaration, calling for primary healthcare for all at a time of widespread health care workershortages in low and middle-income countries (LMIC)[9], many countries with lack of human resourcesadopted polices to train non-physician cliniciansmainly to support care of women and children [10].A reflection of such policies was the development ofcommunity health worker (CHW) programmes to ex-pand access to maternal and child care particularly inrural areas [11–13].Mozambique introduced CHWs, known as AgentesPolivalentes Elementares (APE), in 1978. CHWs are se-lected from and serve the communities in which theylive, with a high level community participation in theirselection process. CHWs are expected to dedicate 80 %of their time on activities related to health promotionand diseases prevention and 20 % to provide basic cura-tive care [14]. Some of their activities related to maternalcare include promotion of antenatal care and post-partum visits, promotion of health facility based deliver-ies and exclusive breast feeding, identification of warningsigns in pregnancy and referral to the health facility. Re-garding child care apart of health promotion and somedisease prevention knowledge, they are trained to man-age malaria, diarrhoea and upper respiratory tract infec-tions, identify warning signs in the new born and refer[14]. The initial CHW training lasts 14–18 weeks andadditional refresher courses are provided regularly [14].Particularly to pre-eclampsia and eclampsia nothing wasincluded in their training manual.Pre-eclampsia is a particularly complex condition.Only recently non-physician clinicians within the healthsystem are being trained to manage this disease. A studyin Malawi demonstrated that different types of non-physician clinicians are capable to care for pregnantwomen including identifying and providing preliminarycare before referring to nearest health facility for furthercare [15]. In 2012, the WHO report on optimization ofhealth workers’ roles, recommended that a variety ofhealth care providers within the health system levelshould be involved in the care of women with pre-eclampsia and eclampsia (namely nurses, midwives andassociate clinicians) by providing antihypertensive andmagnesium sulphate (MgSO4) when appropriate [16].Specifically for CHWs, there is lack of evidence regard-ing their potential role in the management of pre-eclampsia and eclampsia. Often CHWs are seen as op-tion for care mainly in rural areas which leads to pro-gressive increase in their scope of work and tasks.Recently, in Mozambique, for example, CHW weretrained to also provide injectable contraception [17].There are certain concerns regarding the ability ofCHWs providing more differentiated health services,particularly due to their limited literacy and numeracylevel and also because of their already relatively highThe Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 150 of 162workload. However, being present in rural communitieswith limited or no access to health care services, CHWsare regarded as most available option. Thus, within thisscenario, we asked whether CHWs could be involved inthe management of pre-eclampsia and eclampsia andthus contribute for further reduction in maternal mor-tality given that this condition is the third leading causeof maternal mortality.The aim of this article is to present the current stateof knowledge and practices among CHWs regardingpre-eclampsia and eclampsia in southern Mozambique.A better understanding of CHWs perspectives regardingpre-eclampsia and eclampsia management could also beuseful for policy makers to design effective training strat-egies to improve maternal health care. Furthermore, thepaper also aimed to identify gaps in current knowledgeand guide future studies related to CHWs involvementin innovative packages of care such as to control andmitigate effects of pre-eclampsia and eclampsia in re-mote and rural communities.For the purpose of this manuscript, CHWs are repre-sented by formal community agents locally named“Agentes Polivalentes Elementares – APEs”. Further, be-cause at community level, pregnant women are also fre-quently cared by matrons, who are elder women in thecommunity experienced in traditional methods of carewhose skills are acquired on the basis of experience andusually taught by older and more experienced matrons[18, 19], they were also a subject-matter of this study.MethodsStudy areaThis is a component of multi-country national clusterrandomized control trial (cRCT) implemented inNigeria, Mozambique, Pakistan and India, the CLIP(Community Level Interventions for Pre-eclampsia)study (NCT01911494). In Mozambique the cRCT is im-plemented in two provinces, namely Gaza and Maputo,in the southern part of the country (Fig. 1). This studyaims to evaluate a community based intervention con-sisting in measure of blood pressure and proteinuria,clinical management of severe pre-eclampsia with metil-dopa and magnesium sulphate, ability to timely referwomen to the nearest health facility and thus contributefor the reduction of maternal morbidity and mortalitydue to pre-eclampsia and eclampsia.Southern Mozambique is geographically diverse, withcoastal regions as well as large areas of landlocked agri-cultural land. Maputo Province includes the capital city,Matola, located 10Km west of Maputo city, the country’scapital. Maputo province has a population of 1.098 mil-lion. Gaza Province has a total population of 1.362 mil-lion [20]. In general, provinces are divided into districts,administrative posts (AP), localities and neighbourhoods.Each AP covers roughly 500–2,000 inhabitants. The APsincluded in this study area (Calanga, Maluana, IlhaJosina Machel, Três de Fevereiro, Magude, Messano,Macia, Xilembene, Chissano, Mazivila, Chongoene, Chi-cumbane and Chibuto) are largely impoverished ruralareas where the predominant occupations are agricul-ture, livestock rearing, informal trading, migrant labour(mainly to South Africa), handicrafts, and work in pri-vate sugar and rice processing farms. Residents of theseAPs are mostly of the Changana ethnic group and speaka local dialect of the same name (for more details seeTable 1).Study designThis study is based on a formative research exerciseconducted in preparation to the CLIP trial. The for-mative research comprised a mixed methods design, adetailed description of these methods is presentedelsewhere [21].Data collections was conducted based on forms andguides, which were developed centrally by the studycoordination team, used in the other countries wherethe study had been previously conducted (Nigeria,India and Pakistan), and adapted to the local contextof Mozambique.Quantitative data were collected through self-administered questionnaires completed by CHWs. Thequalitative data were obtained through focus group dis-cussions with matrons, and in-depth interviews withCHWs supervisors, district chief medical officers andGynaecologists-Obstetricians. While CHWs, CHW su-pervisors, and district medical officers from all studyarea were eligible to participate, matrons were drawnfrom selected AP, namely Ilha Josina Machel-Calanga,Três de Fevereiro, Messano and Chongoene.Data collection was complemented by a desk review ofexisting documents regarding involvement of CHWs inmaternal and child health such as policies, guidelines,reports and manuals.Self-administered questionnaires targeted all activeCHWs within the study. Recruitment was done throughcontacts with the health facility to which they are linked.Data collection was conducted either in the healthfacility where each CHW reports or at the house ofthe CHW.Focus groups were conducted with matrons. Thisgroup was selected because it is also considered as com-munity based alternative point of care for pregnantwomen and it was important to explore their views andpractices regarding pregnancy complications (includinghigh blood pressure and convulsions), pregnancy man-agement (antenatal care and treatment provision) to gainan understanding of the role of matrons in the contextof expansion of the maternal health care at communityThe Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 151 of 162Fig. 1 Map of the study areaTable 1 Study site characteristicsProvince Regions Population Population of womenof reproductive ageNumber oflocalitiesNumber ofhealth facilitiesNumber ofexisting CHWsNumber of CHWsinterviewedMaputo Maluana-Maciane 13,599 2,481 3 2 4 4Ilha Josina Machel-Calanga 5,720 935 4 2 8 8Três de Fevereiro 25,359 4,089 3 4 3 3Magude 27,388 3,662 7 7 27 23Gaza Messano 9,862 1,671 3 2 3 3Macia 22,349 3,248 2 1 4 4Xilembene 19,501 2,933 1 1 5 5Chissano 18,286 2,950 3 3 3 3Mazivila 14,875 2,215 3 2 4 4Chicumbane 15,684 2,385 1 3 9 9Chibuto 192,927 55,382 19 15 17 9Chongoene 19,501 2,933 6 6 6 6Total 12 385,051 84,884 55 48 93 81Source: Unpublished data from demographic surveillance, health facility assessment (2014) and INE (2007)The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 152 of 162level. As matrons are not formally linked to the healthfacility and are not formally organized as a group there-fore there is no clear ways to systematically identify andtrack them, their total number in the study area is un-known. After being identified with the assistance ofneighbourhood chiefs they were invited to participate inthe study. Focus groups were conducted either at thecírculos (the usual community gathering location), or atthe community leaders’ house, as groups could easily beconvened in these locations.In-depth interviews, which involved all CHW supervi-sors and district medical officers from the study areawere conducted one-on one in the work place of therespondents. The entry points were the district levelmedical officers themselves who in turn identified theCHWs supervisors. As there are no Gynaecologists-Obstetricians in none of the selected districts, they wereidentified through the Associação Moçambicana deGinecologia (AMOG) – The Mozambican Gynaecologistsand Obstetricians Association.Study proceduresDesk reviewIt was conducted to obtain information about existingCHWs and their distribution among study sites, theirtraining profile and scope of work. A variety of docu-ments were reviewed, and both published and unpub-lished information accounted for this exercise. Most ofthe published documents were downloaded from theMozambique Government portal. These included formalpolicy documents and other official documents suchas community involvement strategies, CHW trainingprogrammes, monitoring and evaluation manuals, andmeetings’ minutes and reports.Data collectionData were collected between October 2013 and May2014. Questionnaires were designed to obtain informa-tion concerning CHW preparedness, knowledge andreported skills to manage pregnant women and toperform home-based basic treatment for women withpre-eclampsia. For the purpose of this study we assessedthe following warning signs: high blood pressure,hemorrhage and convulsions. The questionnaire in-cluded 33 items on a five-point Likert scale. This formatwas regarded as appropriate to assess CHWs knowledge,attitudes and practices of CHW and level of confidenceregarding maternal health care provision, and comparefindings not only among all CHWs’ within the studyarea, but also eventually across the countries involved inthe study. In addition, one open-ended question for re-spondents’ comments or additional information was in-cluded. Depending on the number of CHWs percommunity, individual or collective briefing sessionswere held to provide instructions on how to fill it, andwhen required further clarification was given in Chan-gana. Five trained local social science research assistantswere available for clarification when required. The ques-tionnaire took on average 20 min to be completed byparticipants.Focus groups discussion were used to explore theviews of matrons regarding pregnancy complications (in-cluding high blood pressure and convulsions), pregnancymanagement (antenatal care and treatment seeking), andexisting health care delivery practices. Based on the FGDguide, earlier mentioned the same trained local socialscience research assistants facilitated the discussions,which took on average 60 min and were audio recorded.In-depth interviews were conducted with Gynaecologists-Obstetricians, district medical officers and CHW supervi-sors to allow further probing on pertinent issues, such astheir opinions regarding CHW’ ability to identify warningsigns in pregnancy, manage pregnancy complications, andtheir proficiency to administer medications. These inter-views were conducted by two social scientists. Interviewslasted between 30–60 min and were conducted in theworkplace of participants. Field notes and audio record-ings were taken at the time of in-depth interviews.All data collection was led by a Mozambican socialscientist assisted by 5 social science research assistantsemployed by CISM. These researchers were selected dueto their familiarity with the local socio-cultural context,the research topic and their relevant qualitative andquantitative data collection expertise. Team memberswere fluent in Portuguese and Changana, included bothmale and female, and had no prior relationship with theparticipants. The data collection and analyse strategywas overseen by the study PI and co-PI.Data management and analysisInformation obtained through the desk review was sys-tematized and summarized to extract relevant informa-tion regarding CHWs history, role and challenges withregards to maternal and child health care that wasalready part of the scope of work of CHWs.All data captured through questionnaires were sent tothe Manhiça Health Research Center (CISM) for dataentry and management using REDCap [22]. Double dataentry was completed in all questionnaires. The presenceof social science research assistants during the self-administration of the CHWs questionnaires helped tomaximise the data integrity. Before it was sent to thedata Center, the study team members made a revision ofeach questionnaire while in the field. The failures to val-idation rules and double data entry discrepancies werechecked through queries that led to confrontation withthe paper forms. Outliers and missing values were alsochecked. Data was then exported to Stata 13 (StataThe Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 153 of 162Corp., College Station, Texas, USA) for further statisticalanalysis. The demographic characteristics of CHWs andthe study variables of interest are presented using de-scriptive statistics (absolute and relative frequencies,ranges, averages and quartiles). The exact logistic regres-sion based odds-ratio and its 95 % confidence intervalswere used to describe the association between the self-reported ability of the CHWs to recognise warning signsin pregnancy with their demographic characteristics(age, sex, education and years of experience). Given thesample size no multivariate analysis was attempted.Focus group discussions and in-depth interviews weredigitally recorded using Olympus AS-2400 PC® re-corders. Together with the open-ended question fromCHWs questionnaire they were transcribed verbatim bythe same team members who conducted data collection.While in-depth interviews data and that from the open-ended question of the CHW self-administered question-naire were collected and transcribed in Portuguese. Thefocus group discussions were held in Changana andtranslated to Portuguese while being transcribed. Qualitycontrol of transcripts was ensured by listening to audiorecordings and comparing them against the transcriptsto confirm accuracy.The qualitative data were analysed using NVivo ver-sion 10.0 (QSR International Pty. Ltd. 2012). A thematicanalysis approach was taken (see Fig. 2). The codingstructure (based on free nodes, branched nodes, attri-butes and some pre-determined queries) was developedin advance based on the study objectives through a col-laborative discussion between researchers at CISM andUniversity of British Columbia (UBC). Themes weresubsequently adjusted and new themes added as theyemerged from the data. As analysis was to be performedby two teams (CISM and UBC), the coding structuredwas in English.The two Mozambican social scientists coded all tran-scriptions in Portuguese, by reading the text in Portu-guese and labeling the concepts using the codes whichwere written in English. Three IDI and two FGD tran-scriptions were translated from Portuguese to Englishand coded by a social scientist based at UBC for threepurposes: first, to support the discussions on the devel-opment of the coding structure; second, for the UBCcollaborator to be familiar with the raw data, so as to as-sist interpretation; and finally, for quality control of thecoding.To allow the two teams to work independently, thedata was split into two Nvivo projects, but the samecoding structure was used for both teams. Coding con-sensus meetings to discussing data analysis strategy andfindings were held via Skype™. Coding agreementFig. 2 Theme structureThe Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 154 of 162between the coders was very high. When the coding wascompleted the analysed data was merged into single pro-ject managed by the Mozambican team, form which thefinal queries were run.Ethical considerationsEthical approval for this study was granted by the CISMInstitutional Review Board in Mozambique (CIBS_-CISM/08/2013), as well as by the UBC C&W ResearchEthics Board in Canada (H12-00132). Written informedconsent was sought from each participant before datacollection. For the illiterate participants a literate witnesswas involved in the consent process whereby they wereasked to read and explain to the participant the contentsof the participant information sheet. The consent formwas signed by the witness and the field worker, after theparticipant finger print was taken. All identifiable data ofparticipants were codified through attribution of uniqueidentification numbers or pseudonymous to guaranteeanonymity. When needed the respondent was identifiedby stating the administrative post or the province in theillustrative quotes.ResultsParticipant characteristicsIn total, 81 CHW were recruited to the study; correspond-ing to 87 % of all CHW in the study area (see Tables 1 and2). Four CHW, all from Magude, were not included be-cause they were not reachable at the time of recruitmentto this study. Eight CHWs, all from Malehice, were not in-cluded because data collection took place around theflooding period when access to and communication withthe health facilities, the recruitment entry points and datacollection locations was not possible. All eighty-one ques-tionnaire respondents were employed as CHWs at thetime of data collection. Of those, 65 % were female. Formore details on participants’ characteristics see Table 2.Focus groups discussions were carried out with ma-trons from Ilha Josina Machel-Calanga, Três de Fever-eiro, Messano and Chongoene, one for each AP. A totalof five focus groups were conducted involving 46 partici-pants in total, the median age was 43–67 years and mostof them did not have any formal education (Table 3). Intotal, eighty in-depth interviews were conducted: threeCHW supervisors, three district medical officers, andtwo Gynaecologists-Obstetricians (Table 2).The role of community health workers in maternal careCHW policy documents emphasise maternal and childhealth care. Although there is no indication on the num-ber of visits per pregnant women policy documents statethat CHWs should conduct regular home visits duringpregnancy and postpartum (up to 42 days post-partum).During these visits, CHWs interaction with pregnantwomen should focus mostly on health promotion, edu-cation and verification of antenatal care (ANC) attend-ance and to promote hospital-based delivery. The CHWtraining manual has a section dedicated to the care ofpregnant women, with specific attention to pregnancyidentification, the importance of early and regular ANC,and safe practices during pregnancy, birth preparednesscounselling, the importance of delivering at the healthfacility and the identification of warning signs duringpregnancy and delivery. Ninety-five percent of surveyedCHW reported that they are able to identify pregnantTable 2 Questionnaire and in-depth interview Participants’demographic informationCharacteristic CHWs (%)N = 81Other healthprofessionals (%)aN = 8Age20-29 14 (17 %) 1 (12 %)30-39 12 (15 %) 3 (38 %)40-49 25 (31 %) 3 (38 %)> 50 21 (26 %) 1 (12 %)Missing 9 (11 %) 0(0 %)GenderMale 20 (25 %) 3 (38 %)Female 53 (65 %) 5 (62 %)Missing 8 (10 %) 0(0 %)Marital statusMarried 26 (32 %) 3 (38 %)Divorced 3 (4 %) 0(0 %)Widowed 5 (6 %) 0(0 %)Single 38 (47 %) 5 (62 %)Missing 9 (11 %)Highest level of education attainedPrimary level uncompleted 39 (48 %) 0(0 %)Primary level completed 15 (19 %) 0(0 %)Secondary level uncompleted 14 (17 %) 0(0 %)Secondary level completed 1 (1 %) 4 (50 %)Higher degree 0 (0 %) 4 (50 %)Missing 12 (15 %)Years of experience has CHWone year year 21 (26 %) NATwo years 15 (19 %) NAThree years 6 (7 %) NA˃3 years 29 (36 %) NAMissing 10 (12 %) NAa3 CHW supervisors (Bilene-Macia, Manhiça, Xai-Xai), 3 district medical officers(Bilene-Macia, Manhiça, Xai-Xai), 2 Gynaecologists-Obstetricians (Maputo city)The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 155 of 162women in the community and 93 % said that they moni-tor pregnant women on a regular basis (see Table 4).According to focus group discussions, matrons re-ported to provide advice to women throughout preg-nancy, particularly related to traditional practices. Thematrons do not formally offer health services, but whenthere is an emergency in the community they might becalled upon for assistance.Supervisors and district medical officers, hold percep-tions regarding the role of CHWs which are in accord-ance with the existing policy documents, as illustrated inthe quote bellow.“What they [CHWs] do when they find a pregnantwoman is to refer the health facility for antenatal care,to raise awareness of the importance of antenatalconsultation [and] giving birth at the health facility.It is what they do, and they issue a referral slip […] tohealth facility. They always make regular visits until[…] after childbirth also [they] have to make follow-upto see if the child up to five years for example hascompleted the vaccinations [programme]. They alwayshave to make regular visits to that family”.- CHWssupervisor, IDI, GazaCommunity health worker knowledge of the warningsigns in pregnancyCHWs training covers the identification of pregnancywarning signs, such as vaginal bleeding, fever, swelling,convulsions, severe headache, lower abdominal pain, ab-sence of fetal movements, and weight loss.More than half of the CHWs reported having receivedregular training regarding the identification of complica-tions in pregnancy (60 %) and most (93 %) agreed thatthey knew the warning signs in pregnancy. Yet, less thanhalf (38 %) of them reported not being able to identifywarning signs during delivery (see Table 4). Concerningto age, older CHWs had slightly higher chance ofknowing at least one warning sign in pregnancy (OR =1.14; 95 % CI: 1.02-1.34), with relative increase associ-ated with each year of experience or practice. However,no statistically significant association was observed forgender and education level (see Table 5).Regarding haemorrhage, 69 % of CHWs whoresponded to the questionnaire, reported to be able toidentify haemorrhage during pregnancy. Related to pre-eclampsia, only 41 % of CHWs reported to know at leastone warning sign of hypertension in pregnancy (seeTable 4). Female CHWs were less likely (OR = 0.28; 95 %CI: 0.08 - 0.92) to have knowledge on the warning signsof hypertension in pregnancy compared to male CHWs.This difference was not observed when comparing age,education level and years of work as CHW (see Table 5).Seventy percent of CHWs believed they could recog-nise the signs of convulsions. No significant differenceswere observed according to the demographic variablesof interest. Regarding skills to detect pre-eclampsiaand eclampsia, only 10 % of CHWs reported havingthe capacity to measure blood pressure and protein-uria (see Table 4).Despite not having formal training and their mar-ginal role in the care of pregnant women in ruralcommunities, matrons reported having knowledge ofpregnancy, its complications and were able to iden-tify warning signs such as unconsciousness, short ofbreath, weakness, fever, and headache. Regardingpre-eclampsia and eclampsia, matrons were unableto recognise these biomedical terms, but could listseveral symptoms related to these conditions includ-ing high blood pressure, convulsions and loss ofconsciousness. Matrons were unable to establish adirect association between specific warning signs andmaternal death, except for fainting. In such cased,they perceived that the patient dies, not because theimmediate physiological implications of convulsionsor loss of conscience.Table 3 Focus group participant’s demographic informationNr Group Region # of Participants Age (Median) Marital status Occupation Schooling level1 Matrons Calanga 9 67 Married (3)Widow (4)Divorced (2)Farmer (9) Primary (9)2 Ilha Josina Machel 6 55 Married (3)Widow (3)Farmer (6) Never studied (5)Primary (1)3 Três de Fevereiro 12 65 Married (4)Widow (7)Divorced (1)Farmer (12) Never studied (9)Primary (3)4 Messano 10 43 Married (5)Widow (3)Single (2)Farmer (8)Teacher (1)Housewife (1)Never studied (1)Primary (7)Secondary (2)5 Chongoene 9 58 Married (2)Widow (1)Single (6)Housewife (9) Never studied (7)Primary (2)The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 156 of 162Community health worker management and referralpractices for pregnancy complicationsSixty-two percent of CHWs reported having receivedadditional training regarding identification and referralof pregnant women with complications as part of regularcontinuous education programme. Nearly half of theCHWs reported being confident in providing oral medi-cation of any kind (47 %), but a much lower proportion(14 %) reported confidence in specifically providing oralantihypertensives. Very few CHWs (5 %) felt confidentin administering injections of any kind (see Table 4).CHWs supervisors, district medical officers andGynaecologists-Obstetricians showed support for task-shifting to CHWs regarding the identification and timelyreferral of cases before progression to severe pre-eclampsia and eclampsia. However, they showed strongskepticism regarding CHWs’ ability to manage the casesat community-level.Table 4 Community health workers’ questionnaire resultsAgree Neither Agreenor DisagreeDisagree UnknownIdentify pregnant women 77 (95 %) 0 (0 %) 3 (4 %) 1 (1 %)Monitor regularly pregnant women 75 (93 %) 2 (2 %) 2 (2 %) 2 (3 %)Know the warning signs in pregnancy 75 (93 %) 0 (0 %) 3 (4 %) 3 (3 %)Know the warning signs of hypertension during pregnancy 33 (41 %) 0 (0 %) 32 (40 %) 16 (19 %)Know the warning signs of convulsions in pregnancy 57 (70 %) 2 (3 %) 18 (22 %) 4 (5 %)Can identify haemorrhage during pregnancy 56 (69 %) 0 (0 %) 18 (22 %) 7 (9 %)Can identify warning signs during labour 33 (41 %) 1 (1 %) 31 (38 %) 16 (20 %)Can measure blood pressure 8 (10 %) 0 (0 %) 45 (56 %) 28 (34 %)Can measure proteinuria 8 (10 %) 4 (5 %) 42 (52 %) 27 (33 %)Can provide oral medication 38 (47 %) 0 (0 %) 25 (31 %) 18 (22 %)Can provide oral antihypertensives 11 (14 %) 1 (1 %) 39 (48 %) 30 (37 %)Can give injections to pregnant women 4 (5 %) 2 (2 %) 47 (58 %) 28 (35 %)I receive additional training regarding identification and referral of pregnant women withcomplications50 (62 %) 0 (0 %) 24 (30 %) 7 (8 %)I receive regular training to identify complications in pregnancy 49 (60 %) 0 (0 %) 25 (31 %) 7 (9 %)Table 5 Self-reported ability of CHWs to recognise warning signs in pregnancy, pregnancy related HTA, and convulsions inpregnancyTotal Recognise pregnancy warningsignsbRecognise pregnancy hypertension warningsignsRecognise convulsionsN (%) N (%) OR (95 % CI)a N (%) OR (95 % CI)a N (%) OR (95 % CI)aTotal 81 (100.0) 75 (92.6) 33 (40.7) 57 (70.4)SexMale 20 (24.7) 19 (95.0) 1.00 13 (65.0) 1.00 18 (90.0) 1.00Female 53 (65.4) 50 (94.3) 0.88 (0.02 - 11.74) 18 (34.0) 0.28 (0.08 - 0.92)* 34 (64.2) 0.20 (0.02 - 1.00)Missing 8 (9.9) 6 (75.0) 0.17 (0.00 - 3.82) 2 (25.0) 0.19 (0.02 - 1.44) 5 (62.5) 0.20 (0.01 - 2.24)AgeMedian (IQR) 46.0 (35.5 - 50.0) - 1.14 (1.02 - 1.34)* - 0.99 (0.95 - 1.03) - 0.99 (0.95 - 1.03)EducationPrimary 54 (66.7) 52 (96.3) 1.00 22 (40.7) 1.00 38 (70.4) 1.00Secondary 15 (18.5) 14 (93.3) 0.54 (0.03 - 34.01) 7 (46.7) 1.27 (0.34 - 4.68) 11 (73.3) 1.16 (0.28 - 5.73)Missing 12 (14.8) 9 (75.0) 0.12 (0.01 - 1.21) 4 (33.3) 0.73 (0.14 - 3.15) 8 (66.7) 0.84 (0.19 - 4.39)Years working as community health workerMedian (IQR) 2 (1–8) - 1.19 (0.93 - 1.94) - 1.04 (0.97 - 1.12) - 1.09 (0.99 - 1.24)aComputed from exact logistic regression for predict upper 3 levels among the original 5 levels ordinal variablebRecognised at least one warning sign*Overall p-value < 0.05The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 157 of 162“I think that it would not be ideal…blood pressure isnot just any pathology which we can say: let’s createan algorithm and give it to them [CHWs] becauseblood pressure acts in different ways in each patient,thus it is a pathology that has to be managed byexperienced people…people who are trained for that.However, if well trained they can measure bloodpressure only if based on electronic devises, and referthe women to the nearest health facility”.- Chiefmedical officer, IDI, MaputoThe scepticism was even stronger, when discussingthe consideration of administration of injectablemedication by CHWs to manage severe pre-eclampsiaand eclampsia.Even if they are well trained [to administratemagnesium sulphate in the community], I would notsupport… I think that this will perhaps increasematernal deaths related to hypertensive disorders inthe community…will he [CHWs] have and know howto correctly use magnesium sulphate in order tocontrol hypotension and respiratory depression, forexample?”.- Gynaecologists-Obstetricians, IDI,MaputoThis lack of support was based on their perceptionsregarding CHWs limited clinical knowledge and theireventually inability to manage adverse events of inject-able drugs. They also showed concerned about CHWslimited literacy and numeracy levels and short durationof their initial training which does not include adminis-tration of injectable drugs. They insisted that in cases ofan emergency, including convulsions, CHWs shouldimmediately refer to the nearest health facility using thereferral slip with the following information: date, nameof the patient, age, community, referral facility, CHWs’name, reported symptoms and signs, and any first aid orcare provided.Historically, matrons managed women during preg-nancy and delivery. According to focus group findings,matrons reported to currently have less of a role in ma-ternal care, since according to them, the Ministry ofHealth advised them not to manage emergencies anddeliveries at home and encouraged women to seek ante-natal care and delivery at health facilities.“Yes we help [women] giving birth but with the arrivalof the hospital we were forbidden [by the Ministry ofHealth]. [Women] should go to the hospital. It is notbecause we cannot do [the] birth. We cannot do, ourtime ended up. And now we cannot get involved inthese new things [new rules]. Our daughters arebrought to hospital now”. Matrons, FGDs, CalangaHowever, matrons reported to still assist with deliver-ies outside facilities, particularly when they have a re-quest in the late stages of labour. In the management ofpregnancy complications, matrons typically use trad-itional methods. For example, in cases of abortion, ma-trons boil herbs in water, put them in a clay pot and sealit until the day of delivery. Similarly, when matrons en-counter women with convulsions they treat them basedon their traditional knowledge (exposing them to strongsmells) before referring to a health facility.DiscussionThis study was conducted to better understand the po-tential of CHWs, particularly in the provision of obstet-ric care at community level, with focus on pre-eclampsiaand eclampsia. There were no previously published stud-ies regarding the knowledge or competency of CHWs inidentifying or managing HDPs in Mozambique. Thisanalysis showed that despite the fact that CHWs had nospecific training for identification, management and re-ferral of pregnant women with pre-eclampsia andeclampsia, a considerable number of them reported thatcan identify some warning signs commonly occurring inpregnancy including: convulsions, headache, swellingamong other signs. The finding that most CHWs agreedthat they knew the warning signs in pregnancy likely re-sults from the training that they receive on this topic inpreparation to becoming CHWs. The ability of CHWsto identify warning signs in pregnancy is somewhat en-couraging, not enough especially with regards to the linkbetween the warning signs and the respective conditions,considering that identification of pregnant women withcomplications is included in their responsibilities. Thereis further need to improve their knowledge aboutpre-eclampsia and eclampsia, particularly raising theirawareness on the link between hypertension and con-vulsions during pregnancy and on need of urgent re-ferring pregnant women with pre-eclampsia andeclampsia being both life-threatening conditions.Few studies assessed CHW knowledge and competen-cies specifically related to HDP. One study in Ghana,however, showed that CHWs reported a range of bloodpressure thresholds in pregnancy, and these providersdid not uniformly mention that hypertension in preg-nancy was warning sign that needing referral [23]. An-other study, in South Africa reviewed CHW knowledge,beliefs and attitudes related to hypertension in the gen-eral population, and found that CHWs were unaware ofthe causes, outcomes, prevention, and management of it.Moreover, they tended to believe in the use of traditionaltreatments for hypertension instead of evidence-basedbiomedical care, leading researchers to ultimately con-clude that these health workers had insufficient biomed-ical knowledge related to hypertension [24].The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 158 of 162Gender and age were the demographic characteristicswhich showed association with knowledge. The impactof age on this outcomes may be related to life cumula-tive experience as alone the years of practices as CHWdid not shown any differences. It was surprising thatmale CHWs showed more knowledge in relation towarning signs of hypertension when compared to femaleCHWs. This is an important topic for further discus-sions and should be addressed while scaling up the inter-vention taking into account that gender issues can posebarriers to implementation of maternal care [25]. Thisstudy did not find significant differences in CHW know-ledge according to the level of education or years ofwork as CHW. Despite this result, supervisors believethat CHWs’ education level was insufficient for theprovision of treatment for pre-eclampsia or eclampsia.The ability to identify warning signs demonstrates thatthe training content is adequately recalled by CHWs,suggesting that when are well trained they can acquirepractical knowledge and implement community-basedinterventions that can contribute to reduce maternalmortality.Moreover, CHWs currently have health promotionand management responsibilities for other diseases suchas malaria, diarrhoea and upper respiratory tract infec-tions. The implementation of these activities has beensuccessfully reported in various settings, suggesting thatdespite their low level of literacy and numeracy, with ap-propriate training and supervision they are capable ofproviding more differentiated health services at thecommunity-level [26].It was evident from questionnaire responses, thatCHWs are not currently equipped to identify and man-age hypertension in pregnancy. This is in accordancewith the absence of these topics in their training man-uals. Further studies to evaluate the impact of providingequipment and adequate training to assess blood pres-sure, measure proteinuria and manage pre-eclampsiaand eclampsia should be promoted in Mozambique. Ithas been demonstrated in Nepal that with appropriatetraining of maternal health interventions, knowledge,competencies and skills can be substantially improvedamong village midwives [27].This study has shown that CHWs were under pressureto refer pregnant women with pregnancy complications tothe health facilities as recommended during their training,but their inability to identify most of the warning signsspecific for pre-eclampsia and eclampsia may delay thesereferrals. A study of risk factors for eclampsia inMozambique revealed that most referral cases reported noblood pressure measurements in antenatal clinics, indicat-ing poor identification of women at risk [28].CHWs seem to accept to expand their role to includemanagement of pre-eclampsia and eclampsia althoughfew showed confidence in administering injectable medi-cation which is essential for the management of severecases. This low self-confidence is also reflected amongsupervisors, medical officers, including specialists whobelieve that the CHWs are not prepared to identify andmanage any complications raised from the administra-tion of magnesium sulphate or other injectable drugs.This general scepticism can also be attributed to the factthat CHW training does not currently include adminis-tration of injectable drugs. This should be properly ad-dressed for the successful expansion of programmesbased on community interventions in the Mozambicancontext, also taking into account factors such as burdenof work due to additional interventions, duration andquality of CHWs training, regular supervision and medi-cation stock management [29]. Misconceptions amongstsome in the medical community regarding the potentialdangers of magnesium sulphate has contributed to thedrug’s non-use [30]. Such misunderstandings may alsolead to suboptimal practice, such as infrequent bloodpressure and proteinuria measurement, and the use ofdiazepam in place of magnesium sulphate [31, 32]. AtPHC level midwives are trained to, and therefore shouldbe able to, identify and treat women with pre-eclampsia[33]. However, in Afghanistan, midwives did not identifythe need for continued antihypertensive therapy in 34 %of cases [32]. Midwives, nurses and medical doctors alikehave demonstrated poor performance on knowledge-based exams regarding pregnancy complications inBenin, Ecuador, Jamaica and Rwanda, the scores rangedfrom 51 % to 78 % on HDP-related questions [34].Nurses and Auxiliary Nurse Midwives in Nepal similarlyshowed poor knowledge and skills, related to diagnosis,management and monitoring of severe pre-eclampsiaand eclampsia [27]. Nevertheless, a study in Afghanistanhas shown encouraging findings, the midwives wherehighly confident in the administration of magnesiumsulphate (79 % were very confident, while 16 % hadsome reservations) [32].Regarding evidence of the implementation of commu-nity based management of pregnant women, a study inUganda suggests that trained CHW can safely provideinjectable contraceptives [35]. A literature review byMalarcher (2010) also found consistent evidence thatCHWs could provide injections safely, were comfortablewith their ability to administer injections, and theirclients were satisfied [36]. A study in Madagascar con-firmed that clients were satisfied with services receivedfrom the CHW (including their administration ofcontraceptive injections) [37]. Many other countrieshave illustrated the importance of the work provided byCHWs and how they are highly regarded in their com-munities [33]. It is therefore reassuring that this is a win-dow of opportunity to include tasks that are critical forThe Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 159 of 162maternal survival, such as administration of antihyper-tensive drugs. There is a need of further research ad-dressing the ability to administer injectables by CHW inMozambique.Besides CHW, matrons are important and well recog-nised cadres of community-based maternal health careproviders. However, the results of this study have shownthat they are discouraged to assist emergencies and de-liveries at home. Similar results were found in Ghana,where the traditional birth attendants (TBAs) were dis-couraged to undertake deliveries but to refer cases tohealth centres [38]. The role of matrons in pregnancymanagement may be reconsidered due to the shortage ofhealth professionals in remote areas. The accuracy andeffectiveness of matrons’ knowledge and competence isnot well known, as most matrons do not receive formaltraining. Their skills are acquired on the basis of experi-ence and usually taught by older and more experiencedmatrons [18, 19]. Training, supervision and provision ofbasic equipment and better coordination between ma-trons and health facilities would add value to their con-tribution in pregnancy care. It is increasingly recognizedthat TBAs or matrons may have a role to play inimproving health outcomes in developing countries be-cause of their access to communities and the relation-ship they share with women in local communitiesespecially if women are unable to access skilled care dueto long distance from health facilities, lack of money,lack of available transportation and poor health facilityconditions [38, 39].Efforts to include specific maternal health care inter-ventions within the CHW package of training couldcontribute to a reduction in maternal morbidity andmortality.Strengths and limitationsCHWs have limited literacy and numeracy, therefore, itis possible that some respondents faced difficulties inunderstanding elements of the questionnaire. Tominimize this concern, researchers were present duringcompletion of the questionnaires, which may also haveplaced pressure on respondents and eventually effectedtheir responses. The team made clear that their role wasonly to clarify the questions and not to interfere with,nor judge the answers. It was not possible to collect datafrom eight CHWs in Chibuto due to flooding’s; there-fore, this group is not represented. No focus groups orinterviews were conducted with CHWs to complementsurveys responses. The assessment of knowledge andself-efficacy through use of likert scales is limited. Thismethod does not allow respondents to provide contextto their responses. In spite of this limitation, closed-ended questions were felt to be most appropriate giventhe sample size required to obtain representative andcross-country findings and budgetary constraints to con-duct in-depth data collection among such numbers ofCHWs. Despite these limitations, this study has manystrengths. Quantitative methods obtain from a largesample size allowed a good overall representation of theregion. All data was collected and analysed by local re-searchers with familiarity of the region and socio-cultural context. The mixed methods approach was anadditional strength, as triangulation with the qualitativecomponents enriched the quantitative results. This studyprovides novel findings regarding the knowledge andconfidence in addressing the most pervasive pregnancycomplications affecting Mozambicans today. Little litera-ture is currently available regarding community healthworker knowledge related to pre-eclampsia and eclamp-sia, and therefore these results provide unique insights.ConclusionsThe results of this study illustrates that CHWs are awareof pregnancy complications, but have limited knowledgewith regards to pre-eclampsia and eclampsia. There is aneed to promote studies to evaluate the impact of en-hancing their training to include additional content re-lated to the identification and management of pre-eclampsia and eclampsia. As community health workersand matrons are the first point of contact for primarycare, particularly in remote rural areas where otherhealth services are non-existent or difficult to access, ap-propriate training would enforce their ability to identify,stabilize, and refer obstetric emergencies.Additional fileAdditional file 1: Reviewer reports. (PDF 250 kb)AcknowledgementsThe authors would like to thank all participants in the study. They alsogratefully acknowledge the contributions of the Community LevelInterventions for Pre-eclampsia (CLIP) Feasibility Working Group: Rosa Pires,Zefanias Nhamirre, Rogério Chiaú, Analisa Matavele, Adérito Tembe, LinaMachai, Beth Payne, Sharla Drebit, Chirag Kariya and Laura Magee. We alsoacknowledge the support of CISM, University of British Columbia (UBC),Maputo Provincial Health Department (DPS Maputo), Gaza Provincial HealthDepartment (DPS Gaza), Mozambican Obstetrics and Gynecology Association(AMOG), Faculty of Medicine of the Eduardo Mondlane University, Ministry ofHealth (MISAU), National Direction for Public Health, and Community HealthWorkers Programme. This work is part of the University of British ColumbiaPRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment)initiative supported by the Bill & Melinda Gates Foundation. CISM is fundedby Agencia Española de Cooperación Internacional para el Desarrollo.DeclarationsThis article has been published as part of Reproductive Health Volume 13Supplement 2, 2016: Building community-level resilience for the case ofwomen with pre-eclampsia. The full contents of the supplement are availableonline at http://reproductive-health-journal.biomedcentral.com/articles/sup-plements/volume-13-supplement-2. Publication charges for this supplementwere funded by the University of British Columbia PRE-EMPT (Pre-eclampsia/Eclampsia, Monitoring, Prevention and Treatment) initiative supported by theBill & Melinda Gates Foundation.The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 160 of 162Authors’ contributionsHB drafted the manuscript and led data collection and analysis. ES adapteddata tools, supported the analysis and interpretations of the quantitativedata, provided oversight throughout project implementation and manuscriptwriting. KM adapted the tools to the local context, supervised HB,contributed to collection, analysis, interpretation of the qualitative data andrevised the manuscript. MV provided critical manuscript revision, analysequalitative data and provided insight for interpretation. DS and RQcontributed to the conception and design of the study. OA, MS, EM, CM andPvD provided intellectual input to manuscript development regarding thecountry and global context. All authors read and approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interest.Peer reviewReviewer reports for this article are included in Additional file 1.Author details1Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Vila daManhiça CP 1929, Moçambique. 2Department of Obstetrics andGynaecology, and the Child and Family Research Institute, University ofBritish Columbia, 950 West 28th Avenue, Vancouver V5Z4H4, Canada.3Universidade Eduardo Mondlane, Faculdade de Medicina, Av. SalvadorAllende, 702 R/C, Maputo, Moçambique. 4Ministério da Saúde, Av. EduardoMondlane, Maputo 1008, Moçambique. 5Barcelona Institute for Global Health(ISGlobal) /Hospital Clinic - Universitat de Barcelona, Calle Rosselló, 132,Barcelona 08036, Spain. 6Department of Research, Vancouver Island HealthAuthority, Victoria V8R 1J8, Canada. 7Division of Women and Child Health,Aga Khan University, Karachi, Pakistan. 8Department of Obstetrics andGynaecology, St George’s University London, London SW17 0RE, UK.Published: 30 September 2016References1. World Health Statistics 2014. Geneva; 2014. Availabe on: http://apps.who.int/iris/bitstream/10665/112738/1/9789240692671_eng.pdf?ua=1. Accessed 23 Aug 2016.2. WHO, UNICEF, UNFPA WBG, Division and the UNP. Trends in maternalmortality 1990 to 2015. 2015; Available from: http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1 in MaternalMortality 1990 to 2015 full report. PDF. Accessed 3 May 2016.3. Granja AC, Machungo F, Bergstrom S. 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Schwitters A, Lederer P, Zilversmit L, Gudo PS, Ramiro I, Cumba L, et al.Barriers to health care in rural Mozambique: a rapid ethnographicassessment of planned mobile health clinics for ART. Glob Heal Sci Pract.2015;3(1):109–16.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:The Author(s) Reproductive Health 2016, 13(Suppl 2):105 Page 162 of 162


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